2: Osteoporosis/ Paget's

Question 0

OP- path

Answer 0

Osteoclasts

• promoted by TNFa, IL-1, IL-6
• inhibited by OPG, TGFb (normally they are increased by estrogen-> thus increased osteoclasts in hypogonadism)

Question 1

Osteoporosis- risk factors

Answer 1

• White older females
• Genetics
• Low physical activity
• Ca or VitD def
• Smoking or Alcoholism
• Endocrinal disease: increased PTH, T4, cushing disease
• Drugs: steroids (increased Ca in urine and decreased absorption in GI), cyclosporine, anticonvulsant
• Malabsorption*
• PTHrP (lung cancer, MM)
• Hypogonadism

Question 2

OP- sx

Answer 2

• get shorter
• lumbar vertebrae (abd distention, constipation-> increased abdominal pressure-> GERD)
• thoracic vertebrae (decreased chest expansion-> increased infection and restrictive lung disease)
• doweger’s hump
• depression
• hip fracture (avascular necrosis)

Question 3

OP- dx

Answer 3

Dexa scan

• IMP location: hip, wrist, vertebrae
• scan perimenopausal women, frequentHx, steroids for more than 3 months, follow ups
• Z score (compared to reference pop, same age, pop, ethnicity)
• T score (compared to younger population): dx <2.5

Question 4

OP- Dexa scan WHO classifications

Answer 4

T score in Standard deviation
Normal: >-1
Osteopenia: -2.5- -1
Osteoporosis: <-2.5 & fracture

Question 5

OP- rx

Answer 5

1: Estrogen
- increase thromboembolism, stroke, MI, breast cancer
- decrease colon cancer
- new menopausal women w/o coagulative or cardiac condition can qualify for estrogen for a short time
2: Bisphoshonate (dronate) (DOC for steroid induced type)
- can cause esophagitis and TMJ*
3: Tamoxifen/ Raloxifen
- increase endometrial cancer
4: Denosumab- anti RANK L Ab
- cause dermatitis, hypocalcemia
- reduce secondary bone mets
5: Vertebroplasty- cannot gain the height back
6: Kyphoplasty- use balloon & cement to regain the height

Question 6

Paget’s- path

Answer 6

• due to paramyxovirus (RSV, measles)
• genetic factor
• increased sensitivity of RANK to RANK L

Question 7

Paget’s- phases

Answer 7

1: Osteolytic phase
- osteoclast has 100 nuclei and there are more of them
- hyper Ca
- Urinary stones
2: Intermediate phase
3: Sclerotic/ Osteoblastic phase
- abnormal excessive bone growth- easily breakable bones

Question 8

Paget’s- sx**

Answer 8

• increased hat size
• Bowing of long bones (greenstick fracture)
• Pain: dull, deep, gets worse at night
• Warm to touch
• MC bone involvement
• -Pelvis> Femur> Skull> Tibia> Vertebrae
• MC fracture-> subtrochanteric of femur*
• Bruit
• Hearing loss
• Platybasia (flattening of the base of the skull-> compress cerebellum [ataxia, intentional tremor])
• Nerve imingement (cauda equina)
• Conversion into Osteosarcoma**

Question 9

Paget’s- dx- x ray

Answer 9

X ray***

• Vertebrae
• -picture frame vertebrae
• -ivory vertebra
• -brim sign (thickening of ileopectinal line
• Skull
• -osteoporosis circumscripta
• Sun burst appearance with osteosarcoma

Question 10

Paget’s- dx

Answer 10

Bone scan
- dark area is where the lesions are involved
Bone markers
- bone formation (phase 3); ALK phos
- bone reabsorptionn
--deoxypyridinoline
--n telopeptide
--c telopetide

Question 11

Paget’s- rx

Answer 11

1: Bisphosphonate (dronate)
- Pamidronate**
- Zolindronate (fibrosis of TMJ)
2: Osteotomy
- take out a piece of bone so it straightens out